Inclusion of Veterinary Services in national emergency management plans

With human population growth, rapid urbanisation, increasing globalisation, and climate change, the interdependency of human health and animal health is mounting. Therefore, the importance of national emergency management plans (NEMPs) for the mitigation of, and preparedness for, all hazards, including disease epidemics, both zoonotic and zootic, is ever increasing. The authors decided to take a One Health approach by assessing the inclusion of Veterinary Services and animal health in NEMPs, based on geographical region, the date of the NEMP, national income status, and the proportion of the agricultural sector in national gross domestic product (GDP). To carry out the assessment, the authors analysed the publicly available NEMPs of 86 Members of the World Organisation for Animal Health. Of the 86 NEMPs reviewed, only a third expressly mentioned Veterinary Services, almost 60% mentioned zoonotic and/or zootic diseases, and about two-thirds mentioned animals to some extent. The highest correlating factor to the inclusion of animal health in NEMPs was the level of the agricultural sector's contributions to the national GDP. Fisheries and aquaculture were not a major consideration in any of the reviewed NEMPs, especially not in relation to diseases. Based on region, Latin America and the Caribbean exhibited the lowest inclusion rate of animal health in NEMPs. The results demonstrate that the omission of animal health is still a problem. A multi-disciplinary approach that includes veterinary medicine as well as human medicine is vital in the construction and/or revision of NEMPs. Future studies should consider whether or not there is a connection between countries' veterinary capacities and the inclusion of Veterinary Services in their NEMPs and whether or not they have the infrastructure and human resources to put into operation the roles of Veterinary Services as identified in their NEMPs.

Ultrasound-Based Quantification of Emboli during Conventional and Endovascular Aneurysm Repair

Purpose:

To differentiate and quantify the type and number of lower limb emboli occurring during endovascular aneurysm repair, as compared to conventional surgery.

Methods:

Thirty-eight patients underwent elective infrarenal aneurysm repair using a conventional surgical approach in 18 and an endovascular procedure in 20. Emboli were detected using a Doppler ultrasound system with a 2-MHz transducer interrogating the mid superficial femoral artery. Lower limb emboli were differentiated as particulate or gaseous based on the physical distance traversed by the embolic signal.

Results:

Significantly more particulate (median 108 versus 59, p = 0.015) and gaseous (134 versus 46, p = 0.008) emboli were detected during endovascular aneurysm repair as compared to conventional surgery. Clinically, no case of massive microembolization occurred in either group, but one patient in the conventional group required a femoral embolectomy, and three patients undergoing endovascular repair developed self-limiting trash feet postoperatively. In patients undergoing endovascular aortomonoiliac aneurysm repair, there was only a poor correlation between the number of particulate emboli and either procedural duration or operator experience.

Conclusions:

The apparent lack of a relationship between particulate embolization and operative time or technical experience suggests that manipulation of endoluminal devices within the aneurysm sac may not be the sole determinant of intraprocedural embolization. Other as yet undetermined factors may predict patients at high risk for massive embolization.

Aortomonoiliac Endovascular Grafting: Difficult Solutions to Difficult Aneurysms

Purpose:

To describe a refined technique for aortomonoiliac endograft exclusion of abdominal aortic aneurysms (AAAs).

Methods:

A tapered aortomonoiliac graft was prepared from an 8-mm thin-walled expanded polytetrafluoroethylene tube graft predilated proximally to 35 mm and tapered distally to 15 mm. The proximal graft was sutured to a 5-cm-long, predilated Palmaz stent, which was mounted on a 30-mm balloon and backloaded into a 21F packaging sheath. With the patient under general anesthesia and both common femoral arteries exposed, the endograft was anchored in the infrarenal aorta and subsequently passed into one iliac system, where it was anastomosed to the iliac or femoral vessels. The contralateral common iliac artery was occluded, and an extra-anatomic, femorofemoral, or iliofemoral bypass grafting was performed.

Results:

Twenty of the 25 AAAs treated to date with this technique have been successful, with aneurysm exclusion achieved in 18 (2 minor distal endoleaks are scheduled for endovascular repair). The technical failures were analyzed, resulting in enhancements to the technique. Complications included 2 early (< 30 days) deaths, 1 case of minor embolization, 1 transient renal failure, 1 pulmonary embolus, and 1 wound infection. The only late complication was a graft infection localized to the groin.

Conclusions:

Aortomonoiliac endovascular aneurysm repair is effective in patients with AAAs involving the iliac arteries. Short-term results are acceptable, but long-term efficacy must be addressed before this procedure is widely adopted. Technical changes made in response to early learning curve problems have led to a safer, more reliable procedure.

Changes in Referral Practice, Workload, and Operative Mortality after Establishment of an Endovascular Abdominal Aortic Aneurysm Program

Purpose:

To determine the change in referral practice following establishment of an endovascular abdominal aortic aneurysm (AAA) program.

Methods:

A prospective audit of all elective admissions for AAA was established in January 1994 at the initiation of an endovascular AAA program. A comparison was made between this cohort and the elective AAA repairs performed between 1981 and 1993.

Results:

Since January 1994, 213 AAA patients (177 men; median age 73 years, range 54 to 88) have been referred for potential endovascular aneurysm repair. To date, 142 patients have undergone elective surgery (41 endovascular and 101 conventional). Between 1981 and 1993, 304 patients (255 men; median age 69 years, range 45 to 86) had elective aneurysm repair. Comparison of the two time periods has revealed significant increases in the number of tertiary referrals (41.8% versus 9.5%, p < 0.01), annual operations (50 versus 23, p < 0.05), and overall mortality (12% versus 6.7%, p < 0.05), the latter attended by a significant increase in cardiorespiratory comorbidity.

Conclusions:

The higher elective AAA mortality rate since the establishment of an endovascular program reflects a change in referral practice and may be directly attributable to an increase in the number of high-risk patients. An endovascular AAA program has clinical and financial implications for the hospital concerned.

Clinical presentation and outcome of dengue viral infection in live-related renal transplant recipients in Karachi, Pakistan

INTRODUCTION

In Pakistan, dengue viral infection has become hyper-endemic. Renal transplantation is also expanding. We aimed to study dengue in renal transplant recipients (RTR).

METHODS

We conducted a study of RTR reported to be anti-dengue immunoglobulin-M antibody positive from January 2009 to December 2010 at our institution in Karachi and follow their clinical course and outcome.

RESULTS

Median age was 28 years; 75 (73.7%) were males. Clinical presentation included fever in 82 (80.4%), gastrointestinal symptoms in 35 (34.3%), hemorrhagic complications in 9 (8.8%), and thrombocytopenia in 97 (95%), which was of >15 days duration in 24%. Fever was seen less frequently in patients on high-dose (>7.5 mg) steroids as compared with low-dose (≤7.5 mg) steroids. Forty-four patients (43%) had primary and 58 (56.8%) had secondary dengue infection. Dengue fever (DF) occurred in 90 (88%), and dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS) occurred in 12 (11.7%). DHF/DSS was seen in 3 (6.8%) of those with primary and in 9 (15.5%) of those with secondary infection (P < 0.22). In secondary infection, patients on cyclosporine-containing regimen had less severe disease, with DHF/DSS in 22% as opposed to DF in 59% (P < 0.04). Of 102 RTR, 68 (66.7%) had graft dysfunction, 5 of whom died. Of the remaining 63, in 54 patients (85.7%) creatinine returned to baseline by an average of 12.6 days. Of 102 patients, 95 (93%) recovered and 7 (6.9%) died, 6 of whom had bacteremia with sepsis and 1 had respiratory failure. None died due to dengue infection alone.

CONCLUSION

In conclusion, in RTR without life-threatening co-morbidities, the clinical course of dengue infection is mild, with good recovery and preserved renal function.

Digital ischaemia in the digital age

After the accidental injection of epinephrine into a digit, various techniques to try and reverse the ensuing ischaemia were unsuccessful. To identify a further treatment strategy and as members of the admitting team were unfamiliar with digital injection of epinephrine a Google search was performed. Previous cases were described and separate sources indicated appropriate management protocols utilising phentolamine. After administration, an almost immediate reversal of ischaemic symptoms occurred. This highlights the role of the internet as an adjunct in managing unfamiliar situations and practising evidence based medicine.

Is use of a Continuous Autotransfusion System beneficial in emergency abdominal aortic aneursym (AAA) surgery?

BACKGROUND

Allogeneic blood products have become a limited and expensive resource. The Continuous Autotransfusion System (CATS) has been promoted as a method for reducing the need for allogeneic blood transfusion. This study was undertaken to ascertain whether the use of CATS in emergency open AAA surgery has any benefits.

METHODS

This is a retrospective study of all patients undergoing emergency open AAA surgery in our center during a 5-year period (between July 2004 and July 2009). Patients were identified from a prospectively maintained vascular database, and data were obtained from patient records.

RESULTS

CATS was used in 69 emergency open AAA repairs. The median total blood loss was 3,500 mL (range: 751-13,796 mL) but the median volume of packed red blood cells produced by CATS was only 493 mL (~ 2 U). An average of 7 U (range: 0-19 U) of bank blood was still used despite the availability of CATS. The mean hemoglobin 24 hours postoperatively was 10.3 g/dL (6.4-14.1) with a hematocrit of 0.30.

CONCLUSION

The use of CATS in emergency AAA surgery does not seem to reduce the use of allogeneic blood transfusion. This may be because of over transfusion, as reflected by relatively high postoperative hemoglobin levels.

Ultrasound measurement of aortic diameter in a national screening programme

OBJECTIVE

Currently there is no universally accepted standard for ultrasound measurement of abdominal aortic aneurysm (AAA). The aim was to investigate the reliability and reproducibility of inner to inner (ITI) versus outer to outer (OTO) ultrasound measurement of AAA diameter.

METHODS

A prospective study design was used to collect 60 random images of aorta (1.4-7.1 cm). Inner and outer wall diameter measurements were then performed by 13 qualified AAA screening technicians and 11 vascular sonographers.

RESULTS

The mean (range) diameter for all 60 aortas by ITI was 3.91 cm (1.39-6.80) and by OTO was 4.18 cm (1.63-7.09), a significant mean difference of 0.27 cm (95% CI: 0.23-0.32 cm). The reproducibility coefficients for differences between technicians were 0.30 cm (95% CI: 0.24-0.36) for ITI and 0.42 cm (95% CI: 0.35-0.49) for OTO indicating significantly better repeatability using ITI. Finally, 15 images were measured twice in random order by all screeners and sonographers. For AAAs > 5 cm, repeatability was significantly better with ITI than OTO (0.14 vs. 0.21; p = 0.016).

CONCLUSION

There was the expected difference in AAA diameter between the two methods (0.27 cm). However, ITI wall method was measurably more reproducible.

DNA damage in Pakistani pesticide-manufacturing workers assayed using the Comet assay

The production and use of chemical pesticides has increased in recent years. Although the increased use of pesticides may benefit agriculture, they are also the potential source of environmental pollution, and exposure to pesticides can have negative consequences for human health. In the present study, we have assessed DNA damage in blood leukocytes from 29 Pakistani pesticide-factory workers and 35 controls of similar age and smoking history. The workers were exposed to various mixtures of organophosphates, carbamates, and pyrethroids. DNA damage was measured with the single cell gel electrophoresis (SCGE) assay or Comet assay, using the mean comet tail length (microm) as the DNA damage metric. Exposed workers had significantly longer comet tail lengths than the controls (mean +/- SD 19.98 +/- 2.87 vs. 7.38 +/- 1.48, P < 0.001). Of the possible confounding factors, smokers had significantly longer mean comet tail lengths than nonsmokers and exsmokers for both the workers (21.48 +/- 2.58 vs.18.37 +/- 2.28, P < 0.001) and the controls (8.86 +/- 0.56 vs. 6.79 +/- 1.31, P < 0.001), while age had a minimal effect on DNA damage (P > 0.05 and P < 0.05 for workers and controls, respectively). The results of this study indicate that occupational exposure to pesticides causes DNA damage.

Cytogenetic analysis of Pakistani individuals occupationally exposed to pesticides in a pesticide production industry

Although several cytogenetic biomonitoring studies on workers exposed to pesticides have been reported, there is only limited information on this topic from developing countries where pesticides have been widely used over the years. People in developing countries are at higher risk from exposure, due to poor working conditions and a lack of awareness of the potential hazards during manufacturing and application of the pesticides. The present study has assessed the genotoxic effects of pesticides on workers involved in the pesticide manufacturing industry. Subjects in the exposed group (29) were drawn from workers at a pesticide production plant in district Multan (Pakistan). The control group (unexposed) composed of 35 individuals from the same area but was not involved in pesticide production. Liver enzymes, serum cholinesterase (SChE), micronucleus assay and some haematological parameters were used as biomarkers in this study. A statistically significant (P < 0.001) increase in levels of alanine aminotransferase, aspartate aminotransferase and alkaline phosphatase was detected in exposed workers with respect to the control group. There was a significant (P < 0.001) decrease in the level of SChE in the exposed group. Exposed individuals exhibited cytogenetic damage with increased frequencies (P < 0.001) of binucleated cells with micronuclei and total number of micronuclei in binucleated lymphocytes in comparison with subjects of the control group. A decrease (P < 0.001) in cytokinesis block proliferation index similarly demonstrates a genotoxic effect due to pesticide exposure. The results indicate that the pesticide industry workers have experienced significant genotoxic exposure. This study highlights the risk to workers in the pesticide manufacturing industries of developing countries such as Pakistan and the need for implementation of suitable safety measures to prevent/limit exposure to harmful toxins.

The impact of diabetes on current revascularisation practice and clinical outcome in patients with critical lower limb ischaemia

OBJECTIVE

To compare current revascularisation practice and outcome in diabetic and non-diabetic patients presenting with critical limb ischaemia (CLI) to a single vascular surgeon.

METHODS

Data for 113 patients presenting with CLI were collected prospectively over a 3-year period. Forty-four (39%) were diabetic. Treatment was classified as percutaneous angioplasty, arterial reconstruction, primary major amputation, and conservative therapy. Main outcome measures were 30-day mortality, major amputation, survival, and amputation-free survival.

RESULTS

Diabetic patients were more likely to present with gangrene, give a history of angina, be treated with nitrates and statins, and have lower cholesterol levels. No significant differences were found in the initial treatment options between diabetics and non-diabetics: angioplasty 39 vs 26%, surgical revascularisation 34 vs 33%, primary major amputation 9% vs 17%, and conservative treatment 11 vs 19% (p = ns in all). There were eight deaths (7%) within 30-days. At follow-up (1-44 months, median 14 months), rates of major amputation and death for the entire population were 23 and 8%, respectively. The 12-month cumulative survival and amputation-free survival rates were 90 and 72%, respectively. When comparing diabetic to non-diabetic patients, there were no significant differences in the 30-day mortality (6.8 vs 7.2%, p = 0.4), cumulative survival (93 vs 89% at 12 months, log-rank test: 0.00, p = 0.9), amputation-free survival (71 vs 73% at 12 months, log-rank test: 0.00, p = 0.99), and major amputation rates (22.7 vs 23.1% at 12 months, p = 0.96). Similarly, there were no differences in limb salvage rates between diabetic and non-diabetic patients undergoing revascularisation procedures (78 vs 90% at 12 months, log-rank test: 2.04, p = 0.15).

CONCLUSIONS

In current practice, an aggressive multidisciplinary approach in diabetic patients presenting with CLI leads to similar limb salvage, amputation-free survival, mortality, and major amputation rates to those seen in non-diabetic patients. The presence of diabetes should not deter clinicians from attempting revascularisation by means of angioplasty or surgical reconstruction.

Outcome of adult acute lymphoblastic leukemia: a single center experience

OBJECTIVE

To study the outcomes of adult patients with acute lymphoblastic leukemia.

SETTING

Tertiary care hospital.

STUDY DESIGN

Retrospective analysis.

METHODS

Fifty eight adult patients (age >14 years) diagnosed as cases of acute lymphoblastic leukemia were studied with respect to their clinical, morphological and immunopathological features at presentation and their relationship with treatment outcomes.

RESULTS

Forty five (77.5%) of the patients belonged to younger age group with male preponderance. The median age was 20 years and mean age was 25.1 years. Male to female ratio was 3:1. Common presenting signs were lymphadenopathy (17.2%), hepatomegaly (32.7%) and splenomegaly (62%). Laboratory features at presentation revealed: hemoglobin > or = 10 gm/dl in 18 (31%), WBC >50 x 10E9 / L in 18 (31%), LDH more than 1000 IU/L in 44 (75.8%) of patients. Morphology revealed that FAB L1 was seen in 21(37.2%) and L2 in 62 (32.7%). Immunophenotyping showed that 26 (61.9%) were early pre-B ALL, 6 (14.2%) were pre-B ALL and T-ALL were 10 (23.8%). Univariate analysis showed age more than 30 years, male gender, total leucocyte count >50 x 10(9)/L and hemoglobin more than 10 gm/dl to be risk factors for poor outcome. Multivariate analysis revealed age more than 30 years, male sex and total leucocyte count > 50 x 10(9)/L are independent risk factors for poor survival. Patients were treated according to the MRCUKX and XII adult protocols. Thirteen (22.4%) patients died during induction therapy secondary to sepsis and progressive disease whereas 42 (72.4%) patients achieved complete remission. Median survival was 18.6 months and 42% patients were alive at 5-years.

CONCLUSION

Overall survival and disease free survival were comparable to those reported in literature. However, age more than 30 years, male gender and total leucocyte count >50 x 10(9)/L had an adverse impact on overall survival.

Methicillin-resistant Staphylococcus aureus infection in vascular patients

Background

The increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) is a major threat in arterial surgery and poses a considerable therapeutic challenge. The aim of this study was to assess the prevalence of MRSA infection in patients treated in the vascular unit.

Methods

A retrospective case-note review was undertaken to identify the nature of the infection and the outcome.

Results

During 1993–1998, a total of 115 patients (4 per cent of the total) were positive for MRSA. Of these, 67 were colonized and 48 were infected by MRSA. The number of MRSA infections increased yearly (1 per cent in 1994 to 5 per cent in 1998). Of the 48 patients infected by MRSA, one had wound infection following brachial embolectomy which eventually resolved. Two patients had undergone carotid endarterectomy necessitating removal of an infected Dacron patch, one of whom developed a hemiparesis. Eleven patients had undergone elective abdominal aortic aneurysm (AAA) repair (five developed pneumonia, two septicaemia, two wound infection, one a false aneurysm at the site of insertion of an endovascular stent, and one developed crossover graft infection after endovascular AAA repair and died). Five patients had undergone ruptured AAA repair (two developed pneumonia, one wound infection and two developed graft infection and died). Four patients undergoing reconstruction for aortic occlusive disease developed MRSA infection, two of whom died. Twenty-five patients with MRSA infection had undergone lower limb procedures. Five of these had graft infection leading to amputation in three and death in two. One patient developed primary arterial infection following embolectomy resulting in arterial rupture.

Conclusion

These results suggest that the prevalence of MRSA infection in vascular patients is increasing. Infection of aortic grafts appears to be uniformly fatal and lower limb graft infection is associated with a high rate of limb loss.

Durability of angioplasty in treating severe leg ischaemia

Background

Percutaneous transluminal angioplasty (PTA) has recently been accepted as a valuable therapeutic option in patients with severe limb ischaemia. However, despite the increasing use of this technique, there have been concerns that the long-term efficacy of PTA is inferior to that of surgical revascularization. This prospective study reports the outcome of an unselected cohort of patients who underwent balloon angioplasty for severe lower limb ischaemia in a single centre.

Methods

During 1997, 108 patients with 133 severely ischaemic legs were treated by PTA. The median age of the patients (49 per cent men) was 76 years. Symptoms were rest pain in 31 per cent, ischaemic ulceration in 56 per cent and gangrene in 13 per cent. The distribution of risk factors was typical: diabetes 32 per cent, ischaemic heart disease 18 per cent and stroke 16 per cent. Median (interquartile range) follow-up was 16 (12–19) months. There was a mean of 1·7 angioplasty sites per patient, distributed in the iliofemoral (14 per cent), superficial femoral (42 per cent), popliteal (18 per cent) and crural (26 per cent) arteries. PTA was performed luminally in 20 per cent of cases and subintimally in the remainder. Overall, 67 per cent of the lesions were complete occlusions with a median length of 20 (10–40) cm.

Results

Technical success was achieved in 104 limbs, with 29 failures. The outcome of patients with a failed angioplasty (29) was poor, with 14 requiring bypass surgery, 11 undergoing a major amputation and 32 per cent dying after the procedure. In contrast, patients having a technically successful angioplasty had a good outcome after a median follow-up of 16 (12–19) months. In this group there was a 30 per cent overall mortality rate during follow-up. However, 85 per cent of the patients had no symptoms of critical ischaemia and the limb salvage rate was 92 per cent.

Conclusion

PTA is an effective and durable procedure in patients with critical leg ischaemia, with results comparable to those of historical surgical controls. Technical failure of PTA is, however, associated with a dire outcome.

Subintimal angioplasty of isolated infragenicular vessels in lower limb ischemia: long-term results

PURPOSE

To assess the outcome of subintimal angioplasty in treating isolated infragenicular arterial disease in patients with severe lower limb ischemia.

METHODS

A retrospective study reviewed 67 consecutive patients (39 men; mean age 76 years, range 41-96) who underwent infragenicular subintimal angioplasty between March 1997 and May 2000 for ischemia in 70 limbs. The median length of occlusion was 6 cm [corrected] (range 1-10) in the below-knee popliteal arteries, 4 cm [corrected] (range 1-4) in the tibioperoneal trunk, 21 cm [corrected] (range 1-35) in the anterior tibial artery, 10 (1-30) in the posterior tibial artery, and 5 (range 1-20) in the peroneal artery.

RESULTS

The technical and clinical success rates were 86% and 80%, respectively. In the 10 (14%) patients with a technical failure, 3 underwent successful bypass, 4 had an amputation, 1 had a lumbar sympathectomy, and 2 were treated conservatively. Of the 4 (6%) limbs that did not achieve clinical success, 2 patients required femorodistal bypass and their ulcers improved; in the other 2, ulcerations did not heal completely. The cumulative limb salvage rate and freedom from critical limb ischemia (CLI) quantified by Kaplan-Meier life-table analysis were 94% and 84% at 36 months. Mortality rates were 19% at 1 year, 43% at 2 years, and 51% at 3 years. In a subgroup analysis, the rate of CLI was significantly lower in nondiabetics (4%) and than in diabetics (24%, p=0.02), but neither survival nor amputation rates were significantly different.

CONCLUSIONS

Subintimal angioplasty is a safe and effective procedure for treating isolated crural vessels in patients with severe lower limb ischemia.

Adventitial cystic disease of the popliteal artery: diagnosis and treatment. A case report

Adventitial cystic disease of the popliteal artery (ACDPA) is an unusual cause of a unilateral progressive intermittent claudication in young or middle-aged men. In the case described here, ultrasound (US) examination provided the preoperative diagnosis. The lesion was dealt with by simple evacuation of the cyst and excision of the wall. This simple treatment is all that is required in the majority of cases and provides good long-term results.

The impact of MRSA on vascular surgery

OBJECTIVES

To investigate the prevalence of MRSA infection in patients treated in a major vascular unit and examine its consequences.

DESIGN AND METHODS

A retrospective case-note review was performed.

RESULTS

During the period 1993 to 2000, a total of 172 patients (4.4% of total) were positive for MRSA. Of these 97 were colonised and 75 were infected by MRSA. The proportion of wound or graft infections caused by MRSA has increased (4% in 1994 to 63% in 2000). Three patients developed native artery infection (one following aortic stent insertion and 2 following embolectomy). All patients with aortic graft infection died. All patients with infected prosthetic infrainguinal bypass ended up with an amputation.

CONCLUSION

The prevalence of MRSA infection is increasing. Infection of aortic grafts appears to be uniformly fatal and lower limb graft infection is associated with high limb loss.

Methicillin-resistant Staphylococcus aureus infection in vascular surgical patients

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) infection is emerging as a major problem in vascular surgical practice. The aim of this study was to review the management of patients with MRSA infection complicating vascular surgical operations.

METHODS

Data were obtained from the vascular audit, case notes, intensive therapy unit (ITU) notes, high dependency unit (HDU) notes and microbiological records of patients who underwent either arterial reconstruction (n = 464) or limb amputation (n = 110) between April 1994 and October 1998.

RESULTS

Forty-nine vascular surgical patients developed clinical MRSA infection (9%). Clinical MRSA infection in patients who had undergone aorto-iliac reconstruction (n = 18) was associated with a 56% mortality (n = 10) and the most common infections were bacteraemia (55%) and pneumonia (50%). MRSA infection occurred in 17 patients who had undergone infra-inguinal bypass and was associated with a 29% mortality (n = 5). The most common site of MRSA infection was the groin wound (76%) leading to anastomotic dehiscence and death in one patient (11%) and necessitating wound debridement in 4 patients (22%). MRSA infection of the groin wound in the presence of a prosthetic graft (n = 3) led to anastomotic dehiscence in 2 patients, and graft excision in 2 patients. Similar complications were not observed in the presence of an underlying autogeneous long saphenous vein graft (n = 16). MRSA infection following major lower limb amputation (n = 14) was associated with death in 5 patients (36%). Wound infection in 10 amputees (71%) led to revision of the amputation to a higher level in 2 (14%) and wound debridement in 2 (14%).

CONCLUSIONS

MRSA infection has a high mortality in vascular surgical patients in general, and following aorto-iliac reconstruction in particular. Autogeneous vein may confer some protection against local complications following groin wound infection. Strategies aimed at reducing the incidence of infection, including strict adherence to infection control procedures, may reduce the severity of this problem.

Laparoscopic reduction of incarcerated Meckel's diverticulum following abdominal hysterectomy

BACKGROUND

Laparoscopic techniques are increasingly being utilized to diagnose and successfully manage intestinal obstruction.

CASE REPORT

We describe a patient who presented with intestinal obstruction following a recent abdominal hysterectomy. The obstruction was caused by entrapment of a segment of small bowel containing a Meckel's diverticulum within a pouch formed by the peritoneal layer following mass closure of the abdominal wound.

DISCUSSION

We discuss the literature on the abdominal wound closure technique. The role of laparoscopy in dealing with intestinal obstruction is reviewed briefly. We have also summarized the management of an incidental Meckel's diverticulum found at laparoscopy.

In situ replacement of infected aortic grafts with rifampicin-bonded prostheses: the Leicester experience (1992 to 1998)

PURPOSE

Prosthetic graft infection after aortic aneurysm surgery is a life-threatening complication. Treatment options include total graft excision and extra-anatomic bypass grafting or in situ replacement of the graft. The latter option is gaining increasing popularity, but the long-term outcome remains uncertain, particularly in light of the increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA). We performed a prospective nonrandomized study to assess the outcome after graft excision and in situ replacement with a rifampicin-bonded prosthesis for the treatment of major aortic graft infection.

METHODS

In a 6-year period from January 1992 to December 1997, 11 patients (eight men, three women) with major aortic graft infection underwent total graft excision and in situ replacement with a rifampicin-bonded prosthesis. The median age of the patients was 66 years (range, 49 to 78 years). Four patients had a hemorrhage from an aortoenteric fistula, three had a retroperitoneal abscess, two had graft occlusion, one had a perigraft collection shown by means of computed tomography, and one had a ruptured suprarenal false aneurysm. Organisms were cultured from 10 patients.

RESULTS

MRSA was isolated in two patients, both of whom had originally undergone repair of a ruptured abdominal aortic aneurysm. Two patients died (18.2%) within 30 days, and three patients (27.6%) had nonfatal complications (peritoneal candidiasis, transient renal impairment, and profound anorexia). Two patients died late in the follow-up period. Seven patients remain alive and clinically free of infection.

CONCLUSION

The long-term results after total graft excision and in situ replacement with a rifampicin-bonded prosthesis appear to be favorable. However, MRSA aortic graft infection appears to be associated with a poor prognosis.

Vascular surgical society of great britain and ireland: In situ replacement of infected aortic grafts with rifampicin-bonded prostheses

BACKGROUND: Prosthetic graft infection following abdominal aortic aneurysm (AAA) surgery is life threatening. Treatment options include total graft excision and extra-anatomic bypass or in situ replacement of the graft. The latter option is gaining popularity but the long-term outcome remains uncertain, particularly in light of the increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection. A retrospective study was undertaken to assess the outcome after graft excision and in situ replacement with a rifampicin-bonded prosthesis for the treatment of major aortic graft infection. The prevalence of MRSA and its influence on outcome was also assessed. METHODS: Over 6 years between January 1992 and December 1997, 11 patients (eight men) with major aortic graft infection underwent total graft excision and in situ replacement with a rifampicin-bonded prosthesis. RESULTS: The median age was 66 (range 49-78) years. Four patients presented with haemorrhage from an aortoenteric fistula, three had retroperitoneal abscess, two had graft occlusion, one had a perigraft collection on computed tomography and one presented with a ruptured suprarenal false aneurysm. Organisms were cultured from ten patients. Staphylococcus epidermidis and Streptococcus faecalis were predominant. MRSA was isolated from two patients, both of whom had originally undergone ruptured AAA repair. Two patients died and three suffered non-fatal complications. Two patients died during follow-up, one from suspected ongoing MRSA infection and the other from recurrent graft infection. Seven patients remain alive and clinically free from infection, although two were lost to follow-up at 12 and 15 months. CONCLUSION: The long-term results following total graft excision and in situ replacement with a rifampicin-bonded prosthesis appear to be favourable. MRSA infection seems to be associated with a poor prognosis.

The role of screening blood tests in patients with arterial disease attending vascular outpatients

OBJECTIVE

To evaluate the benefits of a policy of performing screening blood tests in new patients with arterial disease referred to the vascular outpatients department.

METHODS

Clinical audit over a 12-month period of all new referrals with arterial disease to the vascular outpatients department at the Leicester General Hospital.

RESULTS

Two hundred and seventy-two patients had at least one blood test performed at their outpatient visit. All of these patients had a full blood count performed, of which 21 results (21%) were abnormal. Further investigation of patients with abnormal results revealed one case of bladder cancer, one case of leukaemia and one patient with polycythaemia. Urea and electrolytes were measured in 269 patients (99%). Of these, 26 (10%) were expectedly abnormal in patients with known renal impairment. A further 27 patients (10%) were identified to have some degree of unrecognised renal impairment. Serum non-fasting glucose was measured in 252 patients (93%). There were 11 unexpectedly raised results, but further investigation of these patients only diagnosed one of these patients as diabetic. Serum cholesterol was measured in 201 patients (74%). One hundred and thirty-two patients (66%) had an abnormally raised serum cholesterol level. Of these, only 12 patients (6%) were known to have hyperlipidaemia.

CONCLUSIONS

Screening new patients with arterial disease in vascular outpatients does identify significant abnormalities, in particular renal impairment and hyperlipidaemia. Correction of these abnormalities may reduce the morbidity associated with contrast induced nephrotoxic acute renal failure, and also contribute to secondary prevention of vascular events associated with raised lipids.

Is endoluminal abdominal aortic aneurysm repair using an aortoaortic (tube) device a durable procedure?

Endoluminal repair of abdominal aortic aneurysm (AAA) is being adopted as a less invasive alternative to conventional open repair in many centers worldwide. Although the initial results are encouraging, the long-term durability of this procedure remains unknown. Endoluminal AAA repair in 29 patients using three different devices (EVT tube Endograft(R), aortouniiliac device, and Stentortrade mark bifurcated system) is described. Overall, 24 procedures (83%) were completed successfully. Complications included two deaths due to microembolization, five early conversions, two chest infections, three patients with buttock claudication, and three patients with trashed foot. Perigraft leaks were detected in four patients (three proximal, one distal) treated with the EVT tube Endograft. Continued aneurysm expansion was observed in three of the patients. One of the leaks was discovered at the 1-year follow-up. In this patient the aneurysmal process was not retarded by endoluminal repair. The findings in this patient may have implications for the durability of this technique. Therefore, careful long-term evaluation of this procedure is recommended prior to its widespread use.

Arterial thrombosis: a complication of loop ileostomy

Restorative proctocolectomy has become the surgical treatment of choice in ulcerative colitis. Most commonly, this is performed as a staged procedure which includes formation of a defunctioning loop ileostomy. High output loop ileostomies are associated with both local and systemic complications. We describe two patients with loop ileostomies who developed acute arterial thrombosis, a complication not previously described, thus further emphasizing the importance of careful management and early reversal of high output ileostomies.

Changes in referral practice, workload, and operative mortality after establishment of an endovascular abdominal aortic aneurysm program

PURPOSE

To determine the change in referral practice following establishment of an endovascular abdominal aortic aneurysm (AAA) program.

METHODS

A prospective audit of all elective admissions for AAA was established in January 1994 at the initiation of an endovascular AAA program. A comparison was made between this cohort and the elective AAA repairs performed between 1981 and 1993.

RESULTS

Since January 1994, 213 AAA patients (177 men; median age 73 years, range 54 to 88) have been referred for potential endovascular aneurysm repair. To date, 142 patients have undergone elective surgery (41 endovascular and 101 conventional). Between 1981 and 1993, 304 patients (255 men; median age 69 years, range 45 to 86) had elective aneurysm repair. Comparison of the two time periods has revealed significant increases in the number of tertiary referrals (41.8% versus 9.5%, p < 0.01), annual operations (50 versus 23, p < 0.05), and overall mortality (12% versus 6.7%, p < 0.05), the latter attended by a significant increase in cardiorespiratory comorbidity.

CONCLUSIONS

The higher elective AAA mortality rate since the establishment of an endovascular program reflects a change in referral practice and may be directly attributable to an increase in the number of high-risk patients. An endovascular AAA program has clinical and financial implications for the hospital concerned.

Results of surgery and angioplasty for the treatment of chronic severe lower limb ischaemia

OBJECTIVE

To aims of this study was to assess and compare the efficacy of PTA and surgery in the treatment of severe lower limb ischaemia.

DESIGN

Prospective 12-month study of 180 consecutive patients with severe chronic lower limb ischaemia.

METHODS

PTA was used as first line therapy whenever possible and appropriate. Surgical revascularisation, primary amputation and conservative therapy were used in eh remaining patients. Patient survival and limb salvage were derived using life table analysis.

RESULTS

Revascularisation was attempted in 135 (75%) patients, with PTA in 82 (46%), surgery in 19 (27%) and a combination of both in four (2%). Overall 12-month survival and limb salvage was 75% and 71%, respectively. Surgery and PTA had significantly higher survival rates (91% and 78%) than primary amputation or conservative therapy (57% and 52%) (p < 0.0001 log rank test). Revascularisation with either surgery or PTA achieved the same limb salvage rate of 76%.

CONCLUSION

A large proportion of patients with severe chronic lower limb ischaemia can be managed by PTA. THis management strategy produces a clinically effective outcome at 1-year.

Acute arterial thrombosis after a long-haul flight

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Role of magnetic resonance angiography for assessment of abdominal aortic aneurysm before endoluminal repair

BACKGROUND

A detailed knowledge of the morphology of the aorta and iliac arteries is an important prerequisite for successful endoluminal abdominal aortic aneurysm (AAA) repair. The best method of preoperative evaluation remains to be determined.

METHODS

A prospective study was undertaken between January 1994 and July 1995 to assess the ability of computed tomography (CT), magnetic resonance angiography (MRA), colour duplex imaging and intra-arterial digital subtraction angiography (IA-DSA) to visualize AAA morphology.

RESULTS

Eighty-two consecutive patients (64 men, 18 women) with AAA were assessed with MRA, contrast-enhanced CT, colour duplex imaging and IA-DSA. Median age was 74 (range 59-87) years and median AAA diameter was 5.7 (range 3.5-9.7) cm. Five patients were unable to tolerate CT or MRA examination. Seventy-seven patients underwent both CT and MRA. Of these, 55 also had a colour duplex scan and 32 underwent arteriography. The scans were assessed by an independent blinded observer. MRA was significantly better (P < 0.01) at visualizing AAA morphology compared with CT and colour duplex imaging. There was no statistically significant difference between MRA and arteriography.

CONCLUSION

MRA is useful in patient selection for endoluminal AAA repair, as it avoids use of iodinated contrast medium and ionizing radiation.